Surrogate Quick Application

Surrogate/Carrier Quick Application

If this is a cell phone number do you want to receive notifications via text messages *

YesNo

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Spouse/Partners Name *

First

Last

Are you an experienced Surrogate *

YesNo

Spouse/Partner Email *

Do you have Medical Insurance *

YesNo

What type of insurance *

Total Number of Times You Have Been Pregnant *

Number of Live Births *

Have You Had Any Pregnancy Complications *

YesNo

If Yes please explain *

Have you ever undergone any fertility treatments (medications, insemination, IVF, acupuncture, etc.) to become pregnant *

YesNo

Dates of Live Birth(s) and Hospital *

How Would You Rate Your Physical Health *

ExcellentGoodAveragePoor

Height *

Weight *

If Yes, please explain *

Have you ever been diagnosed or treated for any emotional disorder *

YesNo

Are you taking any medications *

YesNo

If Yes, please explain *

Do You Smoke *

YesNo

Are you around anyone who smokes *

YesNo

Do You Use Drugs *

YesNo

Do you have any criminal arrests *

YesNo

Are you available to travel if needed *

Yes, anywhereYes, but only within my state of residenceNo

Are you receiving any public assistance *

YesNo

If Yes, please explain *

How did you hear about A Family Tree Surrogacy, LLC *

GoogleBingFrom a Friend/Family*FacebookTwitterOther Social MediaFertility ClinicCraigslistOther

If you were referred by a friend/family member please tell us their name so they qualify for the referral *

By selecting "Agree", you are stating that you will and you have answered all questions to the best of your ability, without purposeful omission or deception. You understand being a surrogate is a serious responsibility and a process that requires maturity, excellent communication, honesty and a willingness to help others *

Agree

By selecting “Agree”, you understand the following: Some of the questions in this application are very personal. No answers will be shared with anyone outside of A Family Tree Surrogacy, LLC without your permission. Certain questions and answers are not shared with recipients and are only used for our internal purposes. *

Agree

By selecting "Agree", you are stating that you understand the treatment involves a psychological evaluation, medical testing, a legal contract drafted by an attorney, and frequent visits to a fertility center. You may need to administer injections to yourself daily, for a period of weeks. You will also undergo blood draws and vaginal ultrasounds at the fertility clinic. Becoming pregnant as a surrogate is not a simple process. *